Introduction

Ever since human beings sat around the fire in caves, they have told stories to help them grapple with life and the struggle to survive (McKee and Fryer, 2002). Stories give us a deeper insight into lived experience - past, present and imagined futures (McAdams, 2007). It can be argued that the art of telling, and listening to, stories is at the heart of what it means to be human, how human beings articulate their experience of the world and make sense of it.

This review explores what story and storytelling is, and whether autobiographical, first-person storytelling has a valuable impact on practice, and can engender positive, meaningful change for individuals who access support. It examines how storytelling has been used across social services to date, considers its value, and highlights some considerations for those creating and using stories. Case study evidence is provided to showcase the benefits of storytelling in practice.

What is story and storytelling?

A story is a real or imagined account of events that describes experience. The terms 'story' and 'narrative' are often used interchangeably. However, some research highlights that story is the informal account of lived experience, whereas narrative is a structured interpretation of story, which includes researcher additions and omissions (Connelly and Clandinin, 1990; East and colleagues, 2010; Haigh and Hardy, 2011).

In the words of Kirkpatrick and colleagues (2007) 'storytelling is the individual account of an event to create a memorable picture in the mind of the listener' (p38). The National Storytelling Network and Scottish Storytelling Centre offer comparative definitions, essentially based around words and actions being used to describe a sequence of events and evoke the imagination of the listener. While storytelling often involves live, person-to-person situations without the use of print or technology, modern easy-to-use video and audio technology provide opportunities for people to create and disseminate stories much more widely and informally. Stories can be oral, written, visual or digital - communicated in various formats and in different voices. The telling is subject to the way a person uses oral (including body language if visual) and written language, or pictures.

Why storytelling is valuable to practice

Stories are used to educate, train, entertain and communicate messages. There is a lot written on the use of storytelling in healthcare (including mental health) and healthcare education contexts, to bring about positive change for patients, and promote best practice for professionals (Kirkpatrick and colleagues, 1997; Roberts, 2000; Gaydos, 2005; Hardy, 2007; Charon, 2009; Haigh and Hardy, 2011). Storytelling has also been used across social services (Cox and colleagues, 2003) and there are many examples available in the Iriss storybank: lx.iriss.org.uk/storybank. However, there is less documented evaluation of how storytelling impacts on practice and the individual. The evidence available on using storytelling in healthcare and healthcare education equally applies to social services. Some of the reasons are detailed below.

Places the person at the centre

Roberts (2000) in a paper on narrative and mental illness highlights that the 'individually meaningful may not be the same as the reproducibly measurable' (p433). He qualifies this with an example of how a man with a long history of schizophrenia identified one particular year in his life as the worst, which was completely at odds with his social ability and clinical response to treatment at the time. It came to light that feelings of rejection and isolation caused by his family situation had negatively affected him throughout that year, which was never picked up by professionals. This resulted in a short sighted analysis of his well being, and one that failed to take account of significant personal and emotional experiences. The telling of story, therefore, gives voice to what experiences mean for an individual, rather than the clinical analysis based on measurable factors alone.

Adds richer dimensions to understanding

Storytelling can communicate the physical (body and verbal language, voice and intonation), intellectual, and emotional aspects of a person in the context of their past or present experiences, which enables a fuller understanding of the individual. Ruggles (2002) claims that a 'good story combines the explicit with the tacit, the information with the emotion' (p2). Charon (2009), a health professional, relates an example of how carefully considering story added to their knowledge and resulted in a positive outcome. The patient, a man who had suffered a major stroke, so passionately expressed the shame of having to rely on the women in his family to push him around in a traditional wheelchair, that it prompted the clinician to not just take account of his immediate medical requirements, but to invest in a motorised wheelchair (rather than an MRI scan). This protected his pride and allowed him to envision a more positive future. This example illustrates how storytelling facilitates richer understanding that forms the basis of good assessment, decision making and positive interventions in practice.

Engenders empathy

Fairbairn (2002) claims that empathy involves the 'attempt imaginatively to inhabit the other's world as that person, rather than the attempt to imagine one's own experiences' (p29). He stresses that while practitioners can care for people without empathising with them, the ability to empathise demonstrates skill in practical care and can help in particular situations, where for example, decisions need to be made on behalf of an individual. Charon (2009), in the course of her interviews with clients, speaks of how she is 'sitting with the self and the body of the patient'.

The Patient Stories digital stories project (Hardy, 2007) also highlights examples of how empathy, especially in relation to understanding cultural diversity, is key to a fuller understanding of a person. The stories offer new perspective and give some experience of the 'other', in contrast to support determined by tick-box exercises and targets underpinned by emotional detachment.

Encourages reflection

Storytelling creates space for professionals to reflect on their own moral compass, and their personal values and practice in relation to other groups (Hardy, 2008; Haines and Livesley, 2008; East and colleagues, 2010; Haigh and Hardy, 2011). 'Telling tales' (Haines and Livesley, 2008), a storytelling module developed by two lecturers to explore communication among different professional groups in relation to safeguarding children, was employed to encourage reflection on their own and other's values and perspectives. 'Telling tales' centred around real-life reflections of a children's nurse who worked with a young boy. What the story highlighted was the different perspectives of both the nurses and social workers towards the boy's situation, and how the meanings implied in the language of one of the groups conflicted with the other. It provided students with an opportunity to reflect on their preconceived assumptions of the nurses and social workers, and to begin to develop shared understandings. This was deemed essential to integrated practice, and key to interprofessional working.

Is open to many truths

Story has the ability to create and communicate many personal truths and not just one objective truth (Reissman, 2000; Bailey and Tilley, 2002). Schwandt (2000) argues that knowledge is something that human beings don't find or access, but create. This is based on the philosophy that knowledge is not predefined or 'out there', but continually changing in light of new experiences and influenced by, for example, shared understandings, culture and language. Denning (2000) asserts that the power of story to bring about change comes not from the story itself but from the reactions that it creates in the minds of the listeners. Stories, therefore, are fluid - interpretations that can change depending on the cultural, social and personal circumstances in which they are told and retold by others. They create spaces for readers or listeners to make their own judgements and own meanings, to adopt an open mindset, rather than accepting them as true, accurate accounts of reality (Koch, 1998; Polkinghorne, 2007).

Represents individual and shared realities

Stories 'convey values and emotions and can reveal the differences and similarities between people's experiences' (East and colleagues, 2010, p17). Where storytelling can elucidate personal life events and their meanings, it can also serve to reveal something about both conflicting and shared social and political understandings, for example around subjects such as gender, race and disability (Riessman, 2000). According to Little and Froggett (2009), 'storytelling has the potential to gain access to the complexity of both individual and shared realities in a way other methods struggle to achieve' (p470). It advocates a participative democracy, aspiring to give voice to marginalised or excluded groups, and provides opportunities to challenge or champion commonly held assumptions and beliefs. Examples of this in practice have been documented - cultural diversity (Luwisch, 2001); racism ( Bell, 2010); disability (French and Swain, 2006); and mental health (Altenberger and Mackay, 2008).

Aids learning and development

In the words of Mckee and Fryer (2002), 'Stories are how we remember, we tend to forget lists and bullet points' (p2). For many of the reasons already discussed, it is evident that storytelling develops important skills and encourages good practice. Storytelling also facilitates a more informal way to learn than traditional teaching methods and is less analytical in its approach. Swap and colleagues (2001) distinguish experiential learning from that of being taught - learning by experiencing something uses a different part of memory than learning by teaching. The crux of the authors' argument is that memories rooted in personal experience are easier to retrieve, so the knowledge sticks and can be applied more readily to practice. The fact that personal stories are grounded in real-life or hypothetically real events, also makes them easier to identify with and locate in memory.

Why storytelling is valuable to the storyteller

Reframes self-identity and encourages personal development

Evidence suggests that the process of personal storytelling enables the concept of self and the life story to connect in a way that facilitates a reframing of identity and encourages personal growth (Roberts, 2000; McLean and colleagues, 2007; Altenberger and Mackay, 2008; Charon, 2009; Scottish Recovery Network, 2012). On imparting a story, an individual expresses the significant events in their own words and in their own time, and is empowered to reflect. The process enables new awareness and new meanings of the self to emerge. These are in most cases, positive new meanings that reformulate the teller's sense of self and helps them move beyond the 'illness' that has defined them. McLean and colleagues (2007) assert that telling negative stories is deemed a more powerful catalyst for creating positive perceptions of self - that reflecting on the detail of a disruptive life event helps shape self-identity much more effectively than a positive story, which more commonly serves to entertain or educate.

Is a relationship that co-produces meaning

The nature of the relationship between teller and listener is key to the outcome of the storytelling process (Connelly and Clandinin, 1990; Davison, Bailey and Tilley, 2002; Gaydos, 2005; Polkinghorne, 2007; Cross, 2009). According to Riessman and Quinney (2005) 'participatory practice that is empowering for clients depends on relationships - a hallmark of social work and narrative' (p395). The storytelling relationship involves a listening and engagement that is different to that of a performer-audience or interviewer-participant. It is a relationship that bridges the divide between the person and those providing support, eg practitioner-service user (Charon, 2009). Gaydos (2005), in relation to nurse-patient relationships, elaborates on a four-step approach: engagement, mutuality, movement and new form. In summary, these four elements involve both parties agreeing to nurture trust, respect, care and empathy in the storytelling relationship, and together create a safe space for reflection, which enables new meanings to emerge.

Promotes resilience

Resilience involves a willingness to turn negative emotions involved in disruptive life events into something strengthening and empowering. East and colleagues (2010) argue that resilience is developed by a process of reflection on meanings, which enables emotional insights. The support of peer and other networks is key to forming bonds and feeling connected to other people. The combination of these factors results in a strength in people, which is based on the premise that life experiences (including negative experiences) offer opportunities for personal growth. This is reflected in the storytelling work of the Scottish Recovery Network around 'recovery' - recovery defined as 'being able to live a meaningful and satisfying life, as defined by each person, in the presence or absence of symptoms' (Scottish Recovery Network, 2006, p1).

Is therapeutic

The therapeutic value of telling a story is often reported in storytelling work (Hardy, 2007; Scottish Recovery Network, 2012). While concern for individuals' well-being in storytelling is often expressed and some tellers have reported a degree of upset in relaying their story, it is recognised that, for the most part, the positives of telling their story far outweigh any emotional distress encountered. It is more often that the act of telling a story and reflecting on it has a cathartic effect and is a catalyst to recovery.

Potential pitfalls of storytelling

The following points are worth considering when creating or using stories.

Subjectivity

Storytelling that aims to voice a collective opinion on social and political issues can run the risk of producing biased results that are based on the views of a select number of individuals, excluding and marginalising 'other' voices. Stories should be used to give voice and to allow for contrasting voices to be heard rather than a representative one. The subjective nature of storytelling also means that people listening may or may not identify or connect with people's stories. A story can disengage a listener if they don't identify with the person and subject matter, or potentially trigger an extreme emotional reaction. This needs to be handled sensitively in workplace education and training.

Ethical considerations

In respect of ethics in storytelling, Josselson (2007) says that it '...is not a matter of abstractly correct behaviour but of responsibility in human relationship' (p538). While, for the most part, those eliciting stories as part of their practice give due consideration to ethical issues (the role of teller, anonymity, who 'owns' the story), Josselson argues that the agreement (contract) should not only focus on informed consent, but also on the relationship between teller and listener. While the explicit agreement details the objective of the storytelling - who will do what, what will be achieved and how the story will be shared, there is also a need to be aware of, and consider, an implicit part which focuses attention and value on the relationship - one that is based on reciprocal trust, rapport, empathy and emotional responsiveness.

Power relationships

Storytellers expressing their stories in a professional context may, for personal reasons, omit details of a story, exaggerate it or even make some of it up. This can be influenced by the role of the listener - whether they are distracted and indifferent or engaged and interested. McLean and colleagues (2007) argue the importance of responsive listening, not only in determining what a person may disclose, but also in determining the outcomes for the teller. They also explain that the personality and the mental health of tellers can influence what will be disclosed and in what way.

The potentially coercive nature of storytelling is also highlighted (Hardy, 2007). Individuals may feel their story is being used for propaganda - to push a specific message to the community, and perhaps even victimise them, which is not an accurate reflection of their experience. The power wielded or relinquished between teller and listener in the storytelling process can, therefore, potentially skew validity and/or blur the truth of the story, and empower or disempower either party in the relationship.

Can be demoralising

It is evidenced in the mental health field that there are negative repercussions for some individuals who don't manage to 'recover' as well as others who tell their stories (Scottish Recovery Network, 2012). While storytelling is, for the most part, a process that brings people closer together and facilitates personal growth, a happy outcome for one person can highlight the unfulfilled outcomes of another. This can leave a person feeling isolated, stuck and demoralised.

Is a word based communication

Personal story is largely concerned with communicating in words and that can restrict people who have communication difficulties such as lack of speech, multiple disabilities, withdrawal and mental health problems. It is important that individuals have their voices heard in whatever way that works for them. Assistive technology and other storytelling techniques, such as visual and photo-based have been employed. Examples of using assistive technology and visual techniques with young people are documented by Waller and Black (2012) and Drew and colleagues (2010) respectively.

Is there a place for storytelling in social services?

There is an onus on services and supports to work in partnership with individuals to achieve outcomes. Self-directed support and the integration of health and social care highlight the need for services to ensure the person is at the centre of care and support. It can be argued that a person-centred, co-productive approach to support is more readily attainable given a fuller picture, and understanding of, a person's life. Findings from research conducted on what service users want from practitioners highlighted the importance of: relationships based on warmth, empathy, reliability and respect; seeing people's lives in the round and not just their problems; practical as well as emotional support; and listening. Listening was cited as the first step towards practice based on co-production (Beresford, 2012). If these findings serve as an accurate indicator of what is desired by, and can achieve change for service users, it can be argued that a potential role emerges for story in assisting practitioners, and those being supported, to work together to achieve outcomes and ultimately improve lives.

As well as facilitating the achievement of personal outcomes, there is a role for storytelling in developing awareness and knowledge around policy - how it impacts on people, and how it can be influenced or changed. The following case studies from health and mental health contexts, provide evidence for use of storytelling in influencing practice, policy and improving people's lives.

1. Patient Voices - journey from story to service redesign

The creation and use of digital stories, through careful facilitation, offers patients and providers the opportunity to grasp and transform their experiences and, in so doing, participate more fully in the community, learning from peers and colleagues rather than from 'experts'.' (Hardy, 2007, p48)

The Patient Voices digital stories programme (Hardy, 2007) was about bringing storytelling and new technology together to discover how it can open up dialogue to improve patient care, promote interprofessional working and, ultimately, result in service redesign. Initiated in 2003, the programme aimed to influence policy as well as practice, show how stories can provide qualitative feedback on the personal realities of care and provide service user led insight into the quality of care. Many of the 100+ video stories created in the programme have been used in health and social care education and at strategic management level in the NHS.

Professionals, carers and patients offered to share their stories in their own words, and provided their own photographs and music of choice. NHS staff and students who listened to the video stories spoke of the power in their honesty, simplicity, brevity and memorableness, and their ability to communicate messages succinctly.

The storytelling contributed to practice by:

Placing the person at heart of care

Developing empathy

Encouraging reflection

Placing value on relationships in providing care

Promoting learning and development

The journey from story to service improvement

↓ Stories

Giving people the opportunity to tell their stories enabled listeners/viewers to reflect and enter into dialogue and discussions on meanings for them and those they care for

↓ Reflection

↓ Dialogue

Reflection and discussion led to empathy and understanding of the person - places them at centre of care and support

↓ Empathy

↓ Person at centre

It was realised that the person is an integral part of the interprofessional education process rather than someone being studied

↓ Interprofessional education

↓ Individual changes

Individual changes in practice were encouraged not only through interprofessional education but due to the person being placed at the centre of care

↓ Organisational change

Service improvement

Individual changes led to collective changes which contributed to overall service improvement

2. Personal narratives - journey from story to 'recovery'

Scottish Government funded research, conducted at Robert Gordon University (Altenberger and Mackay, 2008) and supported by Scottish Recovery Network and See Me Scotland, reveals how personal stories are used in the promotion of recovery and social inclusion by mental health users in Scotland. It involved individuals either recovered or in the process of recovery, sharing their own personal accounts of lived experience. Five purposes of telling personal stories were highlighted:

Promoting recovery - stories inspire hope and contribute to people taking control over their own recovery.

Promoting mental health awareness - storytelling is good at highlighting social issues that have something to say about the importance of mental well-being.

Experts through lived experience - people who tell their stories are themselves 'experts', which breaks down the barriers between clinician/patient.

Personal learning and development - telling and sharing stories develops skills and is a tool for personal growth. For example, some storytellers went on to speak at conferences, joined peer support groups and completed training courses.

Implications for practitioners

Listening to, understanding and empathising with individuals is an integral part of practice and underpins the service user-practitioner relationship. A focus on what experiences mean for a person, rather than on a clinical analysis of their situation, encourages a person-centred approach and a shift away from form filling exercises to seeing the person in the round.

Hearing stories allows practitioners to reflect on their own practice, their judgements and facilitate better interprofessional working. It should be part of everyday practice, but can also be incorporated in practice learning and development. Practitioners should be encouraged to share how they work with individuals through story.

The different ways to tell stories should be considered in practice, especially with those who may have communication difficulties or multiple impairments.

The emotional nature of stories may trigger different responses in practitioners. These may vary from extreme to indifferent.

Changes at practice level can influence whole service improvement. This is especially true in respect of interprofessional working.

While storytelling is for the most part, a positive, therapeutic and cathartic experience for tellers, and the person is empowered to be an 'expert in their condition', due consideration needs to be given to the emotional effects on the person, the relationship in the storytelling process and ethics (especially when producing stories to share more widely).

Conclusion

Personal storytelling is shown to impact positively on practice, and influence better services and better outcomes for individuals. Iriss has created a storybank, which includes practical guides and examples of storytelling projects to aid practitioners use and produce stories effectively.

Hardy P (2007) An investigation into the application of the Patient Voices digital stories in healthcare education: quality of learning, policy impact and practice-based value, Belfast: University of Ulster

Waller A and Black R (2012) Personal storytelling for children who use augmentative communication, in N Grove (ed), Using storytelling to support children and adults with special needs, Oxon: Routledge

Acknowledgements

This Insight was reviewed by Prue Thimbleby (Abertawe Bro Morgannwg University Healthboard in partnership with University of Wales Trinity St David), Beth Cross (University of West of Scotland), Jim Elder-Woodward OBE, Clare Bannister-Phillips (Dumfries and Galloway Council), Gordon Watt and colleagues (Scottish Government), Neil Macleod (SSSC) and Helen Allbutt (NES). Iriss would like to thank the reviewers for taking the time to read and comment on this Insight.